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CA-PTP submitted request for treatment with no response from IC. What now?
#1
My PTP submitted a detailed request for treatment in my case on December 5, 2013, on the DWC RFA forms as required under the new rules in California. The insurance company never responded to this request for treatment. Does their failure to respond bar them from denying the treatment request since it has clearly been more than 14 days since the treatment was requested?

What are my remedies against this national carrier who continues to delay, deny, and ignore requests for treatment? I am represented by attorney but they are long gone in helping get any sort of treatment. Lifetime medical is an absolute joke if you can't ever get anything authorized.
 
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#2
sounds like you may be under california comp rules?
if so, treatment denials are handled thru the Independent Medical Review process:
http://www.dir.ca.gov/dwc/IMR/IMR_FAQs.htm

the DWC has promulgated regulations that provide for penalties to apply when claims administrators and UR companies don't follow UR rules. The UR penalty regulations, found in Title 8, California Code of Regulations, sections 9792.11 - 9792.15, provide an enforcement mechanism to ensure utilization reviews are conducted in compliance with UR regulations.
http://www.dir.ca.gov/t8/ch4_5sb1a5_5_0.html

P.S. if you are going to post regularly you should put your state in your profile to aid responses as rules vary by state.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#3
(01-17-2014, 02:43 AM)1171 Wrote: sounds like you may be under california comp rules?
if so, treatment denials are handled thru the Independent Medical Review process:
http://www.dir.ca.gov/dwc/IMR/IMR_FAQs.htm

the DWC has promulgated regulations that provide for penalties to apply when claims administrators and UR companies don't follow UR rules. The UR penalty regulations, found in Title 8, California Code of Regulations, sections 9792.11 - 9792.15, provide an enforcement mechanism to ensure utilization reviews are conducted in compliance with UR regulations.
http://www.dir.ca.gov/t8/ch4_5sb1a5_5_0.html

P.S. if you are going to post regularly you should put your state in your profile to aid responses as rules vary by state.


Thanks for the info 1171. I get IMR process. However, how can there be an IMR review if the CA never responds to the doctors request for treatment to begin with? Never even got a response. They just ignored the doctors request for treatment.

PS - Yes, I am in California. That's why I start my posts "CA" and spelled out that I am in California. Can't find the option to "EDIT" a profile so I have spelled it out in each and every post.
 
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#4
Found the link... Sorry for that. I have updated it to include my location. Will continue to post my state in all posts so viewers don't have to try and figure out where I am and what rules apply.

Thanks again for the links 1171. Will be having a conversation with my attorney on penalties.
 
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#5
I am assuming this is an accepted injury/body part issues that would allow retrospective UR (e.g. AOE/COE) . I recommend getting a copy of your doctors request RFA with the proof of service page of when it was sent to your claims adjuster. This proof of service page is important as it shows the date it was either faxed or mailed. It also shows if it was sent to only your claims adjuster OR if it was also sent to the UR company. Every insurance carrier has a preference if they want ALL requests sent directly to UR OR if they ONLY want it sent to them, so they can choose to approve it OR send it to UR. I recommend getting the doctors request so you know exactly what was requested and exactly when it was sent. Your attorney should also have this, and when a non compliant UR is taken to court what is needed other than the report is the proof of service page. It sounds like you may already have this report as you stated the date. If not, it can take some doctor's offices up to a month to send a request from the date of the exam and is usually not sent the same day of the exam for example. Your claims adjuster actually had 5 days to ponder if she was going to send to UR, and if the need for additional information would extend it to 14 days.

You need to discuss this with your attorney. In my opinion, a late UR or no UR is grounds for an expedited hearing and under the case law Sandhagen I and II it could be presumed authorized. http://www.dir.ca.gov/wcab/2004-EB-7.pdf Since SB863 and the new IMR process this is untested waters. If you do get a late UR response on this and it is denied, I recommend appealing it, request an IMR and also ask your attorney to request an expedited hearing for late UR and request 5814 penalty. This all should be discussed with your attorney first on how he wants to proceed.

I am in agreement with a lien rep who believes a late UR may possibly be grounds for penalty under late IMR (again untested waters). If defendant fails to perform its UR requirements does the IMR process become involved at all because with no UR denial the injured worker cannot request and begin the IMR process (delay)? Those on the applicant side hope so.

LC 4062(b), as amended, now reads as follows:
If the employee objects to a decision made pursuant to Section 4610 to modify, delay, or deny a request for authorization of a medical treatment recommendation made by a treating physician, the objection shall be resolved only in accordance with the independent medical review process established in Section 4610.5.

LC 4610.5(d) and (e):
(d) "If a utilization review decision denies, modifies, or delays a treatment recommendation, the employee may request an independent medical review as provided by this section."
(e) "A utilization review decision may be reviewed or appealed only by independent medical review pursuant to this section. Neither the employee nor the employer shall have any liability for medical treatment furnished without the authorization of the employer if the treatment is delayed, modified, or denied by a utilization review decision unless the utilization review decision is overturned by independent medical review in accordance with this section."

As a respected lien rep previously wrote and I am in agreement and I will copy verbatim" No authorization from the CA, no denial, delay, or modification from UR = No ability to trigger the IMR process."

Also, LC 4610.5(i) indicates the following:
(i) "An employer shall not engage in any conduct that has the effect of delaying the independent review process. Engaging in that conduct or failure of the plan to promptly comply with this section is a violation of this section and, in addition to any other fines, penalties, and other remedies available to the administrative director, the employer shall be subject to an administrative penalty in an amount determined pursuant to regulations to be adopted by the administrative director, not to exceed five thousand dollars ($5,000) for each day that proper notification to the employee is delayed. The administrative penalties shall be paid to the Workers' Compensation Administration Revolving Fund."

It seems to me that failure by the CA to authorize the RFA, or for UR to deny, delay, or modify the RFA, would be "conduct that has the effect of delaying the independent review process[,]" --- thus subjecting the offending IC/TPA to a possible $5K per day administrative penalty.

The last sentence in LC 4610.1 states if your provider refuses to treat absent written certification from UR and written authorization from the CA: "In no case shall this section preclude an employee from entitlement to an increase in compensation under Section 5814 when an employer has unreasonably delayed or denied medical treatment due to an unreasonable delay in completion of the utilization review process set forth in Section 4610."

Again, these are new waters being tested. It is against the rules for an adjuster not to send a request for treatment to UR, unless the injury is in dispute. I would ask your attorney how he would like to proceed.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#6
So.....
I had a request for an MRI and a nerve study that went unanswered for TEN weeks!!!
I called my adjuster and her supervisor dozens of times each and neither ever replied once. My doctor and the specialist I was seeing were both dumbfounded as to the delays. it even says on my specialists report that they didn't understand why they weren't recieving approval.
I finally told them I was driving down to their location if I didn't get a response in by the end of the week. I lost it, I yelled and screamed into the phone that they can't just ignore me until I go away. I finally got approval that week, but never a phone call...
 
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#7
(01-24-2014, 12:01 AM)California_Help Wrote: I am assuming this is an accepted injury/body part issues that would allow retrospective UR (e.g. AOE/COE) . I recommend getting a copy of your doctors request RFA with the proof of service page of when it was sent to your claims adjuster. This proof of service page is important as it shows the date it was either faxed or mailed. It also shows if it was sent to only your claims adjuster OR if it was also sent to the UR company. Every insurance carrier has a preference if they want ALL requests sent directly to UR OR if they ONLY want it sent to them, so they can choose to approve it OR send it to UR. I recommend getting the doctors request so you know exactly what was requested and exactly when it was sent. Your attorney should also have this, and when a non compliant UR is taken to court what is needed other than the report is the proof of service page. It sounds like you may already have this report as you stated the date. If not, it can take some doctor's offices up to a month to send a request from the date of the exam and is usually not sent the same day of the exam for example. Your claims adjuster actually had 5 days to ponder if she was going to send to UR, and if the need for additional information would extend it to 14 days.

You need to discuss this with your attorney. In my opinion, a late UR or no UR is grounds for an expedited hearing and under the case law Sandhagen I and II it could be presumed authorized. http://www.dir.ca.gov/wcab/2004-EB-7.pdf Since SB863 and the new IMR process this is untested waters. If you do get a late UR response on this and it is denied, I recommend appealing it, request an IMR and also ask your attorney to request an expedited hearing for late UR and request 5814 penalty. This all should be discussed with your attorney first on how he wants to proceed.

I am in agreement with a lien rep who believes a late UR may possibly be grounds for penalty under late IMR (again untested waters). If defendant fails to perform its UR requirements does the IMR process become involved at all because with no UR denial the injured worker cannot request and begin the IMR process (delay)? Those on the applicant side hope so.

LC 4062(b), as amended, now reads as follows:
If the employee objects to a decision made pursuant to Section 4610 to modify, delay, or deny a request for authorization of a medical treatment recommendation made by a treating physician, the objection shall be resolved only in accordance with the independent medical review process established in Section 4610.5.

LC 4610.5(d) and (e):
(d) "If a utilization review decision denies, modifies, or delays a treatment recommendation, the employee may request an independent medical review as provided by this section."
(e) "A utilization review decision may be reviewed or appealed only by independent medical review pursuant to this section. Neither the employee nor the employer shall have any liability for medical treatment furnished without the authorization of the employer if the treatment is delayed, modified, or denied by a utilization review decision unless the utilization review decision is overturned by independent medical review in accordance with this section."

As a respected lien rep previously wrote and I am in agreement and I will copy verbatim" No authorization from the CA, no denial, delay, or modification from UR = No ability to trigger the IMR process."

Also, LC 4610.5(i) indicates the following:
(i) "An employer shall not engage in any conduct that has the effect of delaying the independent review process. Engaging in that conduct or failure of the plan to promptly comply with this section is a violation of this section and, in addition to any other fines, penalties, and other remedies available to the administrative director, the employer shall be subject to an administrative penalty in an amount determined pursuant to regulations to be adopted by the administrative director, not to exceed five thousand dollars ($5,000) for each day that proper notification to the employee is delayed. The administrative penalties shall be paid to the Workers' Compensation Administration Revolving Fund."

It seems to me that failure by the CA to authorize the RFA, or for UR to deny, delay, or modify the RFA, would be "conduct that has the effect of delaying the independent review process[,]" --- thus subjecting the offending IC/TPA to a possible $5K per day administrative penalty.

The last sentence in LC 4610.1 states if your provider refuses to treat absent written certification from UR and written authorization from the CA: "In no case shall this section preclude an employee from entitlement to an increase in compensation under Section 5814 when an employer has unreasonably delayed or denied medical treatment due to an unreasonable delay in completion of the utilization review process set forth in Section 4610."

Again, these are new waters being tested. It is against the rules for an adjuster not to send a request for treatment to UR, unless the injury is in dispute. I would ask your attorney how he would like to proceed.

This is an accepted claim and the request for treatment is within the scope. I have the docs that PTP filed with that proof of service page. Next step is to try to get my attorney to do something with it. They are pretty much long gone when it comes to getting help on the medical side of the claim. They were paid long ago and have moved on.

And i agree that failure to do UR or respond to an RFA creates a situation where NO IMR PROCESS EXISTS. IMR comes into play upon a delay, deny or modification to a treatment request. If IC doesn't do anything, IMR process is mute.
 
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#8
(01-24-2014, 02:23 AM)A cure for pain Wrote: So.....
I had a request for an MRI and a nerve study that went unanswered for TEN weeks!!!
I called my adjuster and her supervisor dozens of times each and neither ever replied once. My doctor and the specialist I was seeing were both dumbfounded as to the delays. it even says on my specialists report that they didn't understand why they weren't recieving approval.
I finally told them I was driving down to their location if I didn't get a response in by the end of the week. I lost it, I yelled and screamed into the phone that they can't just ignore me until I go away. I finally got approval that week, but never a phone call...

I don't know if you are represented by an attorney or not. If you are pro-per filing for an expedited hearing on this issue would have gotten the attention of your adjuster. There are information and assistance officers, two at EVERY WCAB to help injured workers. All you would need is your doctors report and the fax/mail proof of service page. Filing for an expedited hearing is easy and the I&A officers will help you fill out the paperwork if you need help. You can also request penalties for this BS, possibly 5814 penalty. You can still take this issue to court and request penalties on this. You can go back up to two years on ignored/late UR under the Sandhagen ruling. The next time this happens, I recommend call an I&A officer.

They will ignore you if there is no possibility you will take this issue to court.

Some claims adjusters are illegally ignoring and delaying UR in California. To stop this you need to file an expedited hearing and then state you will be requesting penalties at future hearing, as you cannot get penalties at an expedited hearing. Trust me this works a lot better than yelling and screaming.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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